What have you been reading, hearing or TV viewing that has provoked some feelings of comfort or concern about what is happening in the world of medicine, medical care, treatment or science? Ethics is all about doing the right thing. Are you aware of any issues in medicine or biologic science which are being done right, could be improved or in fact represent totally unethical behavior?
Write about them here.. and I will too! ..Maurice (DoktorMo@aol.com)

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Sunday, February 12, 2006

“Good People Doing Bad Things for Good Reasons”

What is ethical or not is often in the eye of the beholder. That is why often the ethics of decisions or acts that we deal with in medicine is established through the process of consensus. And I don’t necessarily mean consensus by only scholars, lawyers or ethicists or even physicians. I think in ethical consensus the many voices of society should be included. I think that an understanding of reason for the divergent views that may occur in ethical analysis can be expressed by what Marcia Angell, former editor-in-chief of the New England Journal of Medicine has said in the past. Perhaps you have already have heard it.“Ethical violations are usually not a case of bad people doing bad things for no good reason, it is usually the case of good people doing bad things for good reasons.” If it were bad people, bad things and bad reasons, there would be no ethical conflicts. The question is whether the acts of those good people carried out for those good reasons best meet the principles of ethics for that particular issue.

Many times in clinical ethics, we find that all of the stakeholders of an issue have meritorious reasons to base their suggested actions. There also may be a meeting of an ethical principle for each action so that there is no strictly unethical violation. The problem arises when one action is inconsistent with another action and we have to decide which act and its ethics trumps another. But trumping may mean that some stakeholders may lose. Therefore, those of us who perform the responsibilities of the hospital ethics committee must remember that we are dealing with good people who have good reasons and perhaps their intended actions are not even that bad except in light of the context of the issue. One of the tools the ethics committee has in this case is compromise. Sometimes compromise mitigates the conflict if even only temporarily. Though it may be only a band-aid in making an ethical solution, it often permits time to get the parties together on a final decision.If,as an example,the issue is end-of-life decision-making and family members are in conflict as to whether enough time has elapsed, on treatment, to be assured that the patient will not recover, a compromise can be often reached. Those of us “doing ethics” should always temper our dogmatic views, if we carry them, to realize that generally we are dealing with good people and their good reasons.. and the “bad” things they may want to do is often just “relatively bad” ..Maurice.

4 Comments:

Doesn't the "bad thing" which is done tend to redefine the type of "reason" it is?

Generally, when "good people" are about to do "bad things" ... it's because they don't see that it's a "bad thing" ... either they're uninformed about the consequences of their actions, or they're compromising by lowering themselves to a position of: "the ends justify the means."

That leaves the definition of "good reasons" in question.

I'm not sure I completely understand the reasoning behind this one, Dr. Bernstein - at the moment, to me, it seems a bit circuitous.

When my babies were children, they occasionally got "the runs." The pediatrician would tell me to withold everything but clear liquids for 24 hours.

For a young mother with a hungry, crying baby ... that was very difficult. My intention was always to make my baby feel better ... if he was crying from hunger, then feeding him would make him stop crying, and for that moment, he would feel better. But the runs would worsen.

My actions were those of "a good person" doing a "bad thing" ... on the surface, it was for a good reason - so that the baby wouldn't hurt from hunger. That didn't make the action itself a good action, though, since in actuality, it made the situation worse.

It wasn't long before I learned that it really wasn't relative after all - if I fed the baby, he got worse, and was in danger of dehydrating. If I allowed the baby to be hungry, and only gave him fluids, he and I would both suffer immensely for a period of time, but the rewards were what we both wanted: his renewed health.

I question whether well intentioned bad actions can be seen as "good reasons" ... unless they're made without full disclosure of what the results of those actions would be in the long term. And then, perhaps the "good person" doing the "bad thing" would be blameless, but the person witholding the information would not be ...

Moof, I am glad you brought up the point: Is a "bad thing" ("bad act") absolutely bad? Well, I don't think so in ethical debate. As I said in my post, what is ethical or not "is often in the eye of the beholder". AND, in addition, it is in the context of the ethical issue. This is what makes "bad" only relatively bad. Thus,with the kind of issues that I was focusing on in my post, clinical ethics, often there is no absolutely "good" or "bad" act or outcome. The best decision to all stakeholders is some sort of a compromise, if that is realistically possible.

In the example you give, you demonstrate how the action of withholding food while ordinarily "bad" for the baby, in the context of acute diarrhea,is a good. So what is bad is relative. And in your example, the end does justify the means.

We don't really see in clinical ethics the documented "bad person" plus "bad things" plus "no good reason" otherwise, thru established ethical consensus, there would be full agreement that the solution of the issue would be a "no brainer" and the act would be unacceptable.If we did see more of this combination, our job would much simpler!!..Maurice.

I would like to think that ethics is NOT in the eye of the beholder. That logic leaves too much room for justifications of any actions. Ethics is not religous doctrine. Ethics is not law. Ethics is not social standards. Ethics is not what feels right. These are all subjected to variables that can change the outcome of the ethical or unethical action. Ethics is simply what we OUGHT to do. Ethics is a code of values that is reasonable and well-founded. Beauty is for the eye of the beholder. Ethics is for everyone, everwhere. It is NOT subjective.

Surely not feeding the baby WAS a good act. If it is in the long run helping the baby then the act is good. You say that this doesn't cause it to be a "good" action, but it absolutely does. If you fed the baby to stop it crying knowing it would make the baby worse then your action is bad, if you fed it only water knowing that although the baby would cry it would save it then the action with that knowledge is good. I would have thought that was obvious.

@anonymous

I don't see how you got to your point. If Ethics is a code of values that is reasonable and well-founded and it is no subjective then who decides on what makes it in to this code? How do we determine what is right and what is wrong? I may disagree with you on a situation but then who out of the two of us should we go with? Of course Maurice stated that a consensus would be viable but some people would still disagree with the outcome. I might think I ought to kill a murderer who is threatening my family in order to save them. It could mean 1 person dying in stead of maybe 4 and therefore be okay. But someone else could say that killing is wrong full stop and my family should die at the hand of this killer rather than me intervene.

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